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Version Date: 11/99 Expiration Date: 07/05,Form Approved OMB#: 0925-0407 |
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"Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial", |
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ANNUAL STUDY UPDATE (ASU), |
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Participant ID: FIELD(9) *FIELD(11)*,"November 23, 1998" |
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*FIELD(12)*, |
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Participant Name: FIELD(10),Study Year: FIELD(13) |
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"If Your Name (Printed Above) Is Incorrect, Please Record Your Corrected Name Below.", |
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Corrected Name: ____________________________________, |
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"1. In the period from FIELD(14) to the present, have you",Yes [] |
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been diagnosed with cancer by a health care provider?,No [] |
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(Do not include basal-cell or squamous-cell skin cancers.),"(If no, men go to item 3; women go to item 4)" |
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2. What type of cancer was diagnosed? (Please record all cancers diagnosed during this period except basal-, |
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cell and squamous-cell skin cancers.), |
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"Type/Site of Cancer (breast, lung, etc) Date of Diagnosis Hospital or clinic where the cancer was diagnosed", |
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_____/______/____, |
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_____/______/____, |
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_____/______/____, |
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"What is the name, phone number and address of the physician who diagnosed the most recent cancer?", |
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Name:______________________________________Phone: (____)_______________________, |
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Address:________________________________________________________________________, |
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"", |
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"3. FOR MEN ONLY: In the period from FIELD(15) to the present, have you taken the medication", |
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Proscar or Propecia (Finasteride)? Yes [],No [] |
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"", |
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4. Today’s Date: ______/_______/______, |
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Month DayYear, |
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5. Who completed this questionnaire? (Please check one), |
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[] Study Participant [] Spouse [] Someone else (SPECIFY)_______________________, |
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"",Relationship |
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6. Comments:, |
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___________________________________________________________________________________, |
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_________________________________________________________________________________________, |
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Thank you for completing this questionnaire. Please return this form in the enclosed envelope, |
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"", |
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"Public reporting burden for this collection of information is estimated to average 5 minutes per response, including time for reviewing instructions, searching", |
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"existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct", |
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"or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments", |
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"regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: NIH, Project Branch", |
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"Office, 6705 Rockledge Drive, MSC 7974 Bethesda, MD 20892-7974, ATTN: PRA (0925-0407). Do not return the completed form to this address.", |
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